A 78-year-old patient has been admitted to your ICU with septic shock of unknown cause. Background medical history includes type 2 diabetes and a prior stroke.
Laboratory tests show the following change in renal indices:
|
Baseline |
On admission |
Adult Normal Range |
|
|
Urea |
15 mmol/L* |
32 mmol/L* |
3.0-8.0 |
|
Creatinine |
150 µmol/L* |
380 µmol/L* |
45-90 |
1) Outline your approach to the assessment of the acute kidney injury in this patient (4 marks)
2)Outline your approach to the management of the acute kidney injury in this patient. (6 marks)
Syllabus topic/section:
2.1.7 Renal Intensive Care – L1.
Aim:
To examine the understanding of renal failure secondary to sepsis and allow demonstration of strategies to avoid this complication.
Discussion:
Candidates who performed well divided their time and answer depth appropriate to the marks allocated. Candidates who referred to the scenario outlined, and then organised their answer accordingly, with specific rationale for assessment and management scored well. The topic is core to daily intensive care practice, and thus some detail (outlining rather than generic listing) of the important assessment and management facets for the patient was expected.
For example, the stem outlined a patient with acute AND chronic renal impairment and this aspect will guide the assessment and management. A prioritised approach to investigations, (instead of a catch all generic list) coupled with detailed goals of therapy, gained more marks.
Writing “Give fluids” or “aim euvolaemia” without mentioning how the clinical goal would be achieved gained less marks.
Consideration of poor cardiac output is an important contributor to AKI in ICU. Acknowledgement of this and addressing this in the management would have improved many candidates' answers. Many candidates spent far longer on assessment (4 marks) than the management section (6 marks) . Details on when and where dialysis was appropriate would have gained more marks than a generic list of indications.
Despite the stem mentioning septic shock of unknown cause many did not address assessment of source, source control issues and antibiotic choice with renal considerations in drug dosage.
|
12.1.1 - Assessment (4 marks) |
|||
|
History |
Little to no specific history relevant to renal failure 0 marks |
Covers basics but without perspective or detail. E.g. fails to consider aetiology of underlying renal impairment. 0.5 marks |
Aetiology of chronic and acute renal impairment. ID reversible causes. Obstructive or infective symptoms, nephrotoxins esop medications. Seek info from nephrologists if possible likely to be seeing one with baseline CR). 0.5-1 marks |
|
Examination |
Generic with little to no renal focus. 0 marks |
Covers basics but without perspective and detail. E.g. fails to consider aetiology of underlying renal impairment. 0.5 marks |
In depth with masses renal tenderness, prostate. CVS signs detailed re shock, BP perfusion, details of volume status. 1 mark |
|
Investigation |
Generic answer with little or no renal specific investigation. <0.5 marks |
Basics of urinalysis, renal and CVS interrogation but lacking in full diagnostic detail or clinical perspective. 0.5- 1.5 marks |
Urinalysis (inc sediment and micro). Imaging and contrast guide. (e.g. if infarction) Prioritised list of investigations with rationale. 1.5-2 marks |
|
12.1.2 |
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|
Management |
Generic answer major errors. <2 marks |
Safe approach with any systemic organisation of facts. g, pre-renal, e.g. fluid discussion with Hb targets. Renal. E.g. pharmacology Postrenal. Details of procedures. 2-3 marks |
All the previous and
4-6 marks |
|
(6 marks) |
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|
Overall organisation to be considered in the marking |
Poor structure and /or failure to address the specifics relevant to the renal impairment. |
A safe and structured approach but missing some detail or clinical perspective. |
Clear systematic and detailed approach to diagnosis and management with a focus on renal failure. |
|
Additional clinical perspective indicating an understanding of balancing the clinically common whilst considering less common but important issues. |
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The detailed notes by the college and the marking rubric have made it easy to craft a model answer which contains the kitchen sink, but much harder to fit everything into ten minutes. What follows is a 258-word answer which would hopefully have passed this SAQ, even though it exceeds the 1600-character ten minute limit.
Assessment:
Management
Gaudry, Stéphane, et al. "Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial." The Lancet 397.10281 (2021): 1293-1300.
indell, Joseph A., and Glenn M. Chertow. "A practical approach to acute renal failure." Medical Clinics of North America 81.3 (1997): 731-748.
Sladen, Robert N. "Oliguria in the ICU: systematic approach to diagnosis and treatment." Anesthesiology Clinics of North America 18.4 (2000): 739-752.
Asfar, Pierre, et al. "High versus low blood-pressure target in patients with septic shock." New England Journal of Medicine 370.17 (2014): 1583-1593.